Fatal systemic mycotic infections in the burned child

Two cases of systemic phycomycotic burn wound infection occurred in severely burned children. Both patients, although treated aggressively, died after systemic colonization through the burn wound by fungi. Modern burn therapy has increased survival of many severely burned children but opportunistic fungal infection remains as an ominous threat. Early recognition, wide excision or amputation, and systemic antifungal agents comprise the current clinical armamentarium against systemic fungal invasion of burn wounds.     

Comparison of wound culture and bronchial lavage in the severely burned child: implications for antimicrobial therapy

BACKGROUND: The relationship of the burn wound flora to microbial pathogens in the tracheobronchial tree has important implications for antimicrobial therapy in the severely burned patient. Management of septic complications is bolstered by surveillance quantitative wound cultures (QWC) and bronchial lavage fluid (BLF) cultures. OBJECTIVES: To compare the organisms present in BLF with those found in QWC and to determine if QWC can predict BLF results. DESIGN: Results of BLF cultures from all patients who underwent bronchial lavage from January 1, 1996, to December 31, 1996, at our institution were compared with QWC data from the same date. Criteria for a positive match included an identical antibiotic susceptibility pattern and biotype. Match rates were calculated qualitatively and quantitatively. RESULTS: In 30 (48%) of the 62 BLF cultures, there was a match between the organism identified in the BLF and the QWC. When strict quantitative criteria were applied, the match rate was only 9 (14%) of 62. Burn size and inhalation injury had no significant effect on match rate. CONCLUSIONS: Whereas the microbial pathogens were similar in the QWC and BLF, linear regression showed no value of QWC in predicting BLF culture results. The difference between qualitative and quantitative match rates suggests cross-colonization between the burn wound and tracheobronchial tree, but little to no cross-infection. The QWC and BLF cultures must be performed independently in determining antimicrobial specificity in the burned patient.     

Complement, opsonins, and the immune response to bacterial infection in burned patients

Studies were performed to evaluate complement, opsonins, and the immune response to bacterial infection in burned patients. Concentrations and functional acitivities of components of the classical and alternative complement pathways were measured in the sera of four septic, two bacteremic, and four nonseptic burned patients. In addition, heat-labile and heat-stable opsonic activity and agglutinin titers directed against the infecting bacterial strains were measured in the sera of the four septic patients and in an additional group of 11 septic burned patients with abnormal complement profiles. Functional activity of the alternative complement pathway and the concentration of properdin were shown to be persistently decreased during eight weeks postburn in the septic, bacteremic, and nonseptic burned patients; reduced classical pathway activity was demonstrated during the initial postburn period only in the septic patients. Two of the 15 septic patients had decreased heat-labile serum opsonic activity for their infecting bacterial strains, which occurred only during the initial postburn period. Heat-stable opsonins and agglutinin titers in the patients' sera directed against the infecting bacterial strains were equivalent to those in normal human sera, except for the agglutinin titers to Streptococcus faecalis which were increased in the patients' sera in comparison to the normal sera. These results indicate that the multiple complement abnormalities which occur in septic burned patients do not predispose these patients to bacterial infection by decreasing serum opsonic activity. Moreover, heat-stable immune IgG antibodies are not produced during septicemia which facilitate opsonization of the infecting bacterial strains in the absence of an intact complement system.     

Fluid resuscitation in the burned child--a reappraisal

Recent reports have suggested that burned adults may be resuscitated with one half the volumes of Ringer's lactate recommended by the popular Parkland formula (4 ml/kg/% burn). Forty children studied with a mean burn size of 45% were initially estimated to require 3 ml/kg/% (modified Brooke formula) but the actual requirement was greater. Burns of 25%-35% required 3 ml/kg/% but those in excess of 35% required 4 ml/kg/% or more in order to achieve adequate cardiac output. It is likely that this apparent increased need in children as compared to adults is the result of greater metabolic rate and insensible water loss.     

The Drosophila tissue polarity gene inturned functions prior to wing hair morphogenesis in the regulation of hair polarity and number

The adult cuticular wing of Drosophila is covered with an array of distally pointing hairs. Mutations in the inturned (in) gene result in both abnormal hair polarity (i.e., hairs no longer point distally), and, in most cells forming more than one hair. We have isolated and characterized a collection of in alleles. Among this collection of alleles are a number of rearrangements that enable us to assign in to 77B3-5. Almost all of the in alleles, including putative null alleles, result in a stronger phenotype on the wing at 18 degrees than 29 degrees. The data argue that the in-dependent process is cold-sensitive. Temperature shift experiments with a hypomorphic allele show that this cold sensitivity can be relieved by several hours of incubation at the permissive temperature at a variety of times in the early pupae, but that this ability ends prior to the start of hair morphogenesis. One new allele showed a dramatic heat sensitivity. Temperature shift experiments with this allele revealed a very short temperature-sensitive period that is a few hours prior to the start of hair morphogenesis. That the temperature during hair morphogenesis is irrelevant for the phenotype of in is consistent with the hypothesis that the only role that in has in wing hair development is to regulate the initiation of hair morphogenesis.     

Antibodies to hair follicles in alopecia areata

Although alopecia areata is suspected to be an autoimmune disease, no direct evidence of an altered immune response to components of the hair follicle has been reported. We studied whether antibodies to normal human anagen scalp hair follicles are present in individuals with alopecia areata. Thirty-nine alopecia areata sera and 27 control sera were tested by Western immunoblotting for antibodies to 6 M urea-extractable proteins of normal anagen scalp hair follicles. At serum diluted 1:80, all alopecia areata subjects (100%), but only 44% of control individuals, had antibodies directed to one or more antigens of approximately 57, 52, 50, 47, or 44 kD. The incidence of antibodies to individual hair follicle antigens in alopecia areata was up to seven times more frequent than in control sera and their level up to 13 times greater and was statistically significant for all five antigens. Tissue specificity analysis indicated that these antigens were selectively expressed in hair follicles. These findings indicate that individuals with alopecia areata have abnormal antibodies directed to hair follicle antigens, and support the hypothesis that alopecia areata is an autoimmune disease.     

Recurrent hyperparathyroidism due to parathyroid autografts: incidence, presentation, and management

Recurrent hyperparathyroidism (HPT) occurs in a small percentage of patients undergoing parathyroidectomy for primary HPT and is usually due to inadequate excision of hyperfunctioning parathyroid tissue in the neck, a missed ectopic and hyperplastic parathyroid, or, less commonly, parathyroid carcinoma and parathyroid autografts. In order to determine the incidence, clinical characteristics, and outcome of patients with recurrent HPT due to parathyroid autografts, we reviewed our experience with 604 consecutive patients operated on for primary HPT between 1965 and 1989. One hundred of these patients received parathyroid autografts consisting of portions of one or more parathyroid glands. Three patients with autografts, placed in the sternocleidomastoid muscle, developed recurrent HPT due to their autografts for an incidence of 3 per cent. Recurrent disease was diagnosed between 62 and 113 months with an average of 89 months. The autotransplants in all three of these patients were from hyperplastic or adenomatous parathyroid tissue. Two patients had a history of neck irradiation. Preoperative thallium scans accurately localized the hyperfunctioning parathyroid tissue in all three patients. At operation, the hyperfunctioning autografts had grown into a discrete mass with a single vascular pedicle and were resected. Histologic examination disclosed either hyperplastic or adenomatous tissue, and corresponded to the histology and location of the original tissue transplanted in each case. Follow-up ranges from 12 to 67 months, with an average of 48 months. All patients remain cured and none require oral calcium supplementation. We conclude that graft-dependent recurrent HPT is due to the autotransplantation of hyperplastic or adenomatous parathyroid tissue and that thallium scanning is instrumental for diagnosis and localization.(ABSTRACT TRUNCATED AT 250 WORDS)     

Micrografting in the treatment of severely burned patients

The micrografting technique, employed to treat patients with extensive TBSA burns and reduced areas of healthy donor skin, was assessed simultaneously with traditional mesh grafts (STSG) or Tiersch grafts in the treatment five severely burned subjects (average TBSA burned 35.6 per cent; average per cent of full thickness wounds 32.6 per cent). At the first clinical control on day 6 post-surgery, 93 per cent of the micrografted area was in situ and health; epithelialization of the wound sites was complete at day 21. Meshed STSG yielded 90 per cent attachment at day 6 post-surgery, with epithelialization complete at 12 +/- 2 days post-surgery. Functional results were equivalent no matter what technique was used, while aesthetic results were better in the areas where micrografting was carried out. Although the micrograft technique is labour-intensive, if the expansion needed is at least 1:6, the aesthetic and functional results obtained are comparable to, or better than, those with meshed grafts. Also, large segments of micrograft are not compromised if a small area of mesh becomes detached, and epithelialization is faster and more uniform, enabling a reduction in both infection and length of hospital stay.     

The stigma hypothesis: The sex variable in face to face interactions with the physically disabled.

80 undergraduates were interviewed by a same- or opposite-sex handicapped or nonhandicapped interviewer. Interviewers were both actual amputees who wore their prostheses in the nonhandicapped conditions. Interviews covered 4 topics: sex, religion, sports, and social activities. Ss had significantly shorter interviews in the handicapped condition than the nonhandicapped condition. Contrary to expectations, there were no significant interactions between sex of interviewers or Ss and handicap conditions. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mercury in human hair and relation to fish consumption in Bangladesh

Human scalp hair mercury concentrations were determined in 219 hair samples from male individuals from different regions of Bangladesh. Total hair mercury concentrations were very low with a mean value of 0.44 +/- 0.19 micrograms Hg/g (range 0.02-0.95) for a moderately elevated fish consumption averaging 2.1 kg/month (range 1.4-2.6). A highly significant positive correlation (r = 0.88, P < 0.001) was found between fish consumption and hair mercury concentration. Neither age, region nor occupation had any influence on the hair mercury content. Our results in agreement with literature values, are described by equation (X = 183Y + 0.16) linking calculated daily methylmercury intake (X, mg) and hair total mercury level (Y, micrograms/g). Low concentrations in hair were linked to extremely low levels of daily mercury intake, the determining factor being remarkably low mercury levels in Bangladesh fish.     

Pain in the face

The outstanding cause of pain in the face is dental disease, but various neuralgias and infections such as maxillary sinusitis require consideration. A careful history and examination is the basis of diagnosis.     

Changes in adenine nucleotide and mitochondrial metabolism of the kidney of burned rats and their relation to insulin

In rats with third-degree burns, the blood glucose level increased remarkably, with a concomitant suppression of insulin secretion from the pancreas after an oral glucose load. The energy charge (ATP + 1/2 ADP/ATP + ADP + AMP) levels of the kidney decreased to 0.659 as compared with 0.858 of controls at 8 hr after the burn (p less than 0.001). The phosphorylative activity of the kidney mitochondria fell to one third of controls at 8 hr after the burn (p less than 0.001), and that of heart mitochondria decreased to approximately 70% (p less than 0.005); the fall in liver and brain was less remarkable. The decrease in mitochondrial phosphorylative activity was accompanied by a reduction in the respiratory control ratio, P/O ratio, and state 3 respiration. The concentrations of cytochrome a(+a3) in the kidney mitochondria decreased to 69.9% of controls at 8 hr after the burn (p less than 0.001), those of cytochrome b to 82.6%, and those of cytochrome c + c1 to 75.3% (p less than 0.001). The decreased energy charge and oxidative phosphorylation of the kidney in burned rats were remarkably restored by subcutaneous administration of insulin. It is suggested that a reduction in insulin secretion from the pancreas may play an important role in initiating an impairment of adenine nucleotide and mitochondrial metabolism of the kidney.     

Endothelial F-actin changes in the alkali burned rabbit cornea

The healing mechanism of corneal endothelium after alkali burn was not completely understood. Rabbit cornea was burned with 1N sodium hydxoside for 1 minute. Endothelial F-actin was stained with NBD-phallacidin in regular sequence to find out the details of endothelial healing after alkali burn. F-actin was completely destroyed leaving a sharp margin against the unaffected area 1 hour after the burn. In the 3, 5 and 7 day specimens, highly active F-actin reactions were noted at the wound margin. New multiple F-actin layers, arising from the intact endothelium near the wound margin, were noted in the 9 day specimen. In the 8 1/2 month specimen, the endothelial defected area was covered by large primitive cells, each of which showed F-actin fiber bundles in the cytoplasm with a large nuclear shadow. Nearly all of the large primitive cells showed F-actin fibers arranged in shapes of cell junctions. Twelve months after the burn, endothelial defects were not found. Nearly all of the endothelial cells were normal in size and shape except for some mushroom-like projections toward the anterior chamber in some areas. Nineteen months after the burn, the endothelial cells were normal. Endothelial wound healing process can be continued even 1 year after the alkali burn in rabbit cornea.     

Mother and child personality characteristics related to parental marital status in child guidance cases.

Tested the hypothesis that parental personality contributes to the difficulties of children from broken homes. More MMPI records of 44 divorced and separated (DS) mothers indicated personality disturbance (p     

The contribution of a bacterially isolated environment to the prevention of infection in seriously burned patients

A new system of patient protection from bacterial crossinfection called the Bacteria Controlled Nursing Unit (BCNU) is described, based on strict environmental control of a 6 x 10 foot area surrounding the patient's bed rather than the entire patient room or isolation ward, plus the ability to deliver all medical care without entering the protective environment and maintaining all monitoring, life support, and i.v. equipment outside the controlled environment. The clinical effectiveness of this system in the treatment of burn patients has been studied and compared with the effectiveness of single room isolation on a burn isolation ward and conventional isolation techniques on an open burn ward. The studies show that the BCNU is significantly more effective in preventing bacterial cross-contamination than conventional precautions (3.8% vs. 13.1%, P < 0.001; and 8% vs. 22.8%, P < 0.001) over a two and four week period. The studies also indicate that there was a significant increase in the probability of infection occurring following cross-contamination than occurring after auto-contamination (65% vs. 39%, P < 0.005), emphasizing the importance of preventing cross-contamination in reducing the overall infection rate in seriously burned patients. Clinical evaluation of the unit proved it to be compatible with intensive nursing and medical care without increasing the nurse to patient ratio. The unit provided sufficient control of bacterial cross-infection to allow reduction in mortality and improvement in the effectiveness of burn care through routine prompt excision of burn eschar and immediate wound closure to be carried out in severe and massively burned patients without a limiting threat of bacterial burn wound sepsis.